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bpplcltfons Will Be Proces4ed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: % � APPLICATION <br /> A (F h UMP&WELL <br /> n-Transferable, Revocable, Suspendable) <br /> /D <br /> HEALTH PERMIT r <br /> (COMPLETE IN TRIPLICATE) WATER WATER QUALITY, . <br /> Application is hereby made to the San Joaquin:Local Health District for a permit to construct and/or installthe work herein described.This application_ is <br /> made in compliance with San"Joaquin County Ordinance No.1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 4925 'Veronica City/Town Stockton <br /> Owner's Name B rtoll` hook Phone 931-5546 _ <br /> Address __ sarnp as a"hcwe_ _ City l� <br /> Contractor's Name _Moormant s `Wath . Systems License#t 267696 Business Phone 931-3210 <br /> I Contractor's Address - '6Emergency Phone <br />' Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No r. <br /> TYPE OF WORK'(CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ 'DESTRUCTION❑ ' <br /> WELL CHLORINATION.❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION IR PUMP REPAIR El <br /> REPLACEMENT l f I <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> _—Sewage Cesspool/Seepage Pit Other ! <br /> Property Line Private Domestic Well �� Public Domestic Well 9 /V <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ; ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> f ❑ CATHODIC PROTECTION ❑ ROTARY T <br /> 4 ype of Grout f. <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: .. <br /> PUMP INSTALLATION: Contractor Moorman' s [Nater Systems t <br /> € Type of Pump ubmersible H.P. 2 D <br /> PUMP REPLACEMENT: 91 State Work DonePulled existing u .and replaced-with 2 HP <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate pproximate Depth ' <br /> `.;. Describe Material andAProcedure <br /> I <br /> I hereby certify that I-have prepared this-application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws,'aA&rules and regulations Of the San Joaquin Local Health District. <br /> Homeowner or licensed agehl's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not/employ]any-personinsuch manner..as-to become subject to workman's compensation laws of California." .� <br /> Contractor's hiring or sub-con1ractingsignature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final.inspection. <br /> - 1 i — <br /> Signed X � .Title: . � ���� i — <br /> Date: <br /> j (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> rPHASE I <br /> Application Accepted By - Date <br />` Additional Comments: <br /> Ph aGrout Inspection �P�h Firt�M Inspection <br /> _ ..Inspection_By Date Inspection By_. �. _ Date - '��6 <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH -' ❑ January 1 &Received By January 31 ❑ July 1 &Received By Jury 31 <br /> 1)- . r t ` ' t , - REMIT <br /> BILLING }-REMITTANCE _ $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> ..FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 7 71 <br /> Z_e',v'erzrl5y_ - Date ,- -Receipt No, Permit No trance ate Mailed .- - -Delivered-. _..ti.. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E. A2ELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />